Recent Head Injury Research Articles

Scandinavian Neurotrauma Guidelines: Frequency of intracranial hemorrhage in patients over 65 years old and on anti-platelet medication

PurposeIn 2013, the Scandinavian Neurotrauma Committee, produced an evidence-based guideline for the use of Computed Tomography (CT) in patients presenting following recent (<24 h) head injury (HI). A head CT scan is recommended for medium-risk patients with a Glasgow Coma Scale (GCS) score of 14–15, who are > 65 years old and on anti-platelet medication. The aim of this study was to determine the prevalence of intracranial hemorrhage (ICH) on head CT scans in this population, and to test for associations between ICH and baseline characteristics, symptoms and objective clinical findings. MethodsThis register-based retrospective study determined the prevalence of ICH on head CT scans performed over a 1-year period based on written CT-reports. Patient medical charts and imaging records were examined for data on symptomatology, objective findings and comorbidities. ResultsThe study population included 325 unique head CT scans with a 5.2% prevalence of ICH. Risk ratios (RR’s) signified higher risk of ICH with a GCS score of 14 compared to a GCS score of 15 (RR 5.35, 95%CI 2.14–13.47). ICH risk was lower in patients on Clopidogrel medication compared to Acetylsalicylic Acid medication (RR 0.33, 95%CI 0.12–0.93). ConclusionsThe associations between ICH and the GCS score call attention to the importance of comprehensive clinical examination of HI patients to minimize CT overuse. The implications for patients and healthcare resources in scanning patients > 65 years on anti-platelet medication should be determined by future prospective studies.

Endoscopic evacuation of chronic subdural hematoma with rigid and flexible endoscope: case report

Introduction: Subdural haematoma (SDH) is a common neurosurgical condition after head trauma requiring evacuation to prevent secondary brain injury. The first choice of management in these patients is a large craniotomy or burr-hole evacuation. However, sometimes due to lack vision during drain tube insertion or irrigation the authors might land up in a complication like cortical bridging vein rupture, haemorrhage etc. Also, the management of septate chronic SDH (CSDH) with multiple neo-membranes does not have a well-defined surgical approach. Recently, endoscopic evacuation has been reported to a be a feasible method for evacuation in acute, subacute and chronic SDH patients. Presentation of case: A 65-years-old male patient presented with a history of recent head injury and symptoms of headache and urinary incontinence of 7 days (Glasgow Coma Scale Score 15/15). Computed tomography scan revealed CSDH at both fronto-parietal convexity more on right side. Discussion: The authors reported our initial experience on a typical case of an older patient with chronic subdural haematoma and its evacuation with the assistance of both rigid and flexible endoscope. The authors could visualize cortical bridging veins and neo-membranes intraoperatively and guided our drainage tube accordingly to avoid inadvertent haemorrhage. There was no recurrence of symptoms postoperatively. Thus we achieved apparent successful evacuation of the CSDH in this patient in a 6-month follow-up. Conclusion: Endoscopic evacuation of CSDH proves to be an effective minimally invasive modality and more studies are required on larger patient groups with long-term follow-up imaging to confirm its superiority.

22 Head Injury and Executive Functioning in the MIDUS Cohort

Objective:It has been well established that sustaining a head injury can result in cognitive impairments, but there is little research on the impact of head injuries within middle-aged and older adult samples. Given the two most common samples for head trauma research are athletes and military service members, most of this literature presents findings of individuals under 35 years old. It is important to study head injury outcomes in older samples because greater lengths of time may have passed since the injuries occurred, which may influence findings. Additionally, research indicates that head injuries can lead to measurable executive functioning difficulties - a cognitive domain previously established as susceptible to cognitive ageing-related decline. Therefore, the current investigation seeks to assess the connection between history of head injury and executive functioning performance in middle-aged and older adult participants.Participants and Methods:The current study examined 1150 participants from the 2nd wave of the Midlife in the United States cohort (MIDUS) and 801 participants of the MIDUS refresher panel. As a part of the biomarkers study, participants indicated how many head injuries they experienced (up to three) along with whether they were hospitalized and the year the injury occurred. As a part of the cognitive study, participants completed a battery of measures that were combined into a single Z-scored executive functioning measure. Regression was used to evaluate the association between self-reported head trauma and executive functioning, controlling for age and gender. Post hoc analyses examined hospitalization and recency of head injury.Results:Of the 1951 included participants, 70.7% reported zero head injuries, 20.8% reported one head injury, 5.8% reported two head injuries, and 2.7% reported at least three head injuries. History of head trauma was not associated with lower levels of executive functioning (F[3,1945]=2.68, p=.38). Furthermore, executive functioning performance was not associated with hospitalization for head injury (b=-.04, p=.31) or recent head injuries (b=-.04, p=.70).Conclusions:The current results do not provide evidence of decreased executive functioning performance linked to history of head injury in middle-aged and older adults. These findings are inconsistent with earlier literature suggesting that executive dysfunction is associated with prior head trauma. It is important to consider, however, that the operationalization of executive functioning as a cognitive domain is controversial and produces significant debate. Therefore, the present results solely indicate a lack of connection between previous head trauma and executive functioning, specifically as assessed by the current definition and measures. The present analyses were limited by the broad inclusion of all head injuries rather than a narrowed scope of specifically concussions or mild traumatic brain injuries. However, the study had the advantage of being adequately powered via a large sample size. The current results suggest that additional research is needed within middle-aged and older adult samples to investigate possible connections between head trauma and executive functioning performance using alternate definitions and assessments.

Sport-related Structural Brain Injury in High School and College American Football Athletes, 2002-2020: Effect of Lystedt Law.

A previous report revealed an average of 7.2 (0.67 per 100,000 participants) sport-related structural brain injuries (SRSBIs) with macroscopic lesions per year in high school (HS) and college football players. The Lystedt law and other rule changes have been implemented with intent to reduce the risk of brain injury in football. To update the profile of SRSBIs in HS and college football players and evaluate the efficacy of legislation intended to reduce brain injuries. Descriptive epidemiology study. Level 4. We retrospectively reviewed 18 academic years (July 2002 through June 2020) of SRSBIs catalogued by the National Registry of Catastrophic Sports Injuries. The incidence of SRSBIs was assessed at the HS level during the pre (July 2002 through June 2009), transitional (July 2009 through June 2014), and post (July 2014 through June 2020) universal adoption time periods of the Lystedt law. In addition, the incidence of SRSBIs during the second half of the study (2011-2012 through 2019-2020) was compared with the first half of the study (2002-2003 through 2010-2011). During the study period, there was a total of 228 SRSBIs (12.7 per year, 1.01 per 100,000 participants): 212 (93%, 11.8 per year, 1.00 per 100,000) in HS athletes and 16 (7%, 0.89 per year, 1.17 per 100,000) in college athletes. There were 52 fatalities (2.9 per year, 0.22 per 100,000 participants) with 46 (2.56 per year, 0.22 per 100,000) in HS athletes and 6 (0.33 per year, 0.43/100,000) in college athletes. There was no significant difference in risk of HS total SRSBIs or fatalities during the 3 Lystedt periods. The risk of combined SRSBI cases [relative risk (RR) = 1.22, P = 0.13] and fatalities (RR = 1.20, P = 0.52) was similar in the second half of the study compared with the first half of the study. Despite implementation of rule changes intended to reduce head injury, in particular the Lystedt law, the incidence of SRSBIs has remained unchanged. Further research is necessary to develop effective prevention programs for SRSBIs. SRSBIs remain a persistent problem in HS and college American football. The recent head injury rule changes have not been effective at reducing SRSBIs.

Knowledge about head injury in police custody staff and implications for training

Head injury is prevalent in prisoners and is associated with offending behaviour. Awareness and assessment of the occurrence and effects of recent head injury is important and should occur at an early stage in the criminal justice system. This study looks at knowledge about detainees with a recent head injury in police custody and considers the implications for training of custody officers.Questionnaires about perceived training needs and knowledge about head injury were completed by 67 custody officers in Scotland. All officers reported a need for further training about head injury and the most common areas of need were perceived to be assessment, early management and long term effects. Knowledge and past training seemed to be more focussed on awareness of potentially catastrophic brain injury and a limited understanding of impairment of insight and of emotional and behavioural effects was evident.There is a need for routine training about recent effects of head injury for custody officers to include the effects on insight, emotional and behavioural effects in detainees in addition to training on catastrophic outcomes which tends to be the main focus of current practice.

A-22 Neurorehabilitation Improves Emotional Domain Symptoms in Active and Retired NHL Players

Abstract Purpose: The prevalence of concussions in the National Hockey League (NHL) has been identified as approximately 1 concussion per 16.67 games, and the long-term effects of traumatic brain injuries are being highlighted in recent research. These long-term consequences may be due to chronic symptoms, especially neuropsychological symptoms, from unaddressed neurological dysfunction. Methods: A neuro-rehabilitation clinic treated 14 active or retired NHL players with symptoms relating to head injury an average of 2.47 years after their most recent head injury. A 5-day, multi-modal neurorehabilitation program was administered in 10 one-hour treatment sessions. Each session consisted of a combination of photobiomodulation, repetitive peripheral somatosensory stimuli, neuromuscular reeducation, vestibular rehabilitation, orthoptic exercises, cognitive exercises, and/or off-vertical axis rotation utilizing a multi-axis rotational chair. Results: On intake, the average overall symptom severity score of the SCAT5 graded symptom checklist was 31.42, and the average severity of emotional domain symptoms (Nervousness/Anxiety, Irritability, Sadness, More Emotional) was 5.86. Of the 14 players, 12 players reported symptoms in the emotional domain on intake while only 6 players reported emotional domain symptoms on exit. On average, emotional domain symptom severity score decreased by 81.71% compared to the 72.27% decrease in total symptom severity.: Conclusions: This neurorehabilitation program has shown to be beneficial at decreasing overall symptom severity in NHL players with symptoms post-head injury, especially symptoms that may be described as neuropsychological. The authors suggest further research be performed with a larger sample size and a follow-up study be performed to assess progression/regression.

A CORRELATION OF NEUROCYSTICERCOSIS AND IGG4 ANTIBODIES

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: In endemic regions, 30% of patients presenting with epilepsy, have evidence of neurocysticercosis. In the US, between the years of 2003 and 2012, there were more than 18,000 hospitalizations for neurocysticercosis. A study done in 2002 showed that IgG4 was found in the sera of patients with cerebral cysticercosis 97.8% of the time. Reliance on immunological assays holds importance due to the lower costs in comparison to imaging studies in impoverished areas. This case presentation follows a patient with a ring-enhancing brain lesion, positive cysticercosis antibodies, and positive IgG4 cells on tissue biopsy. CASE PRESENTATION: A 56-year-old male with a past medical history of hypertension, recent head injury and no other risk factors, presented for evaluation of syncope. Before the syncopal episode, the patient was seen by the primary physician for sustained injury to his head with complaints of recurrent fevers, headache, and blurred vision. The patient was prescribed steroids and antibiotics but did not feel any improvement and ended having a syncopal episode with a brief loss of consciousness. Magnetic resonance imaging of the brain with contrast showed a 17mm right mid corona radiata/mid-lateral ventricle peripherally enhancing mass with surrounding white matter edema and centralized restricted diffusion. Patient was admitted to the intensive care unit and treated with antibiotics, steroids, and antiepileptics. Stereotactic brain biopsy showed brain parenchyma with mildly increased cellularity consisting primarily of glial cells suggestive of reactive tissue. All labs and immunological studies were negative except for positive Cysticercosis IgG Antibody. Computed tomography of the abdomen and pelvis was positive for a 3 cm low-density lesion in the right lobe of the liver for which biopsy showed rare CMV inclusions in infected cells on a background of storiform fibrosis and lymphoplasmacytic inflammation with numerous IgG4 positive cells. The patient was started on albendazole and over the course of a few days, symptoms significantly improved. DISCUSSION: Brain biopsy showed only reactive tissue, hence to ensure no other primary lesion is present, further imaging tests were ordered which led to the revelation of the liver lesion and the biopsy was pathognomonic for IGG4 related disease, however, due to a lack of other necessary diagnostic criteria (serum IgG4 above 135 and histopathology showing IGG4 positive cells greater than 40%), the conclusion was not reached. However, due to the ring-enhancing lesion and positive cysticercosis IgG antibody, neurocysticercosis was higher on the differential as IgG4 is the most commonly found antibody in serum or CSF. CONCLUSIONS: Our findings of a correlation between neurocysticercosis and IgG4, strengthen the promise of a better immunodiagnostic tool thereby fighting the issues of accessibility and cost-effectiveness for endemic areas. REFERENCE #1: O'Neal SE, Flecker RH. Hospitalization frequency and charges for neurocysticercosis, United States, 2003-2012. Emerg Infect Dis. 2015 Jun;21(6):969–76. REFERENCE #2: Huang B, Li G, Jia F, Liu F, Ge L, Li W, et al. Determination of specific IgG4 for diagnosis and therapeutic evaluation of cerebral cysticercosis. Chin Med J (Engl). 2002 Apr;115(4):580–3. REFERENCE #3: Legatowicz-Koprowska M. IgG4-related disease: why is it so important? Cent-Eur J Immunol. 2018;43(2):204–8. DISCLOSURES: No relevant relationships by Rahul Dadhwal, source=Web Response no disclosure on file for Lauren Howard; No relevant relationships by Alamgir Khan, source=Web Response No relevant relationships by Katrina Rathjen, source=Web Response No relevant relationships by Salim Surani, source=Web Response

Effectiveness of Osteopathic Manipulative Medicine vs Concussion Education in Treating Student Athletes With Acute Concussion Symptoms.

Concussion, a type of mild traumatic brain injury, is a disruption in normal brain function due to head injury. New-onset symptoms from concussion vary, likely depending on the areas of the head and neck affected; they can be severe and debilitating. Current treatment options are limited and difficult to individualize. Osteopathic manipulative medicine (OMM) can aid musculoskeletal restrictions that can potentially improve concussion symptoms. To assess concussion symptom number and severity in participants with concussion who received either OMM or an educational intervention. A randomized controlled trial was conducted at the New York Institute of Technology Academic Health Care Center. Patients presenting to the center with concussion-like symptoms due to recent head injury within the previous 7 days provided consent and were randomized into 2 intervention groups, receiving either 1 OMM treatment (n=16) or 1 concussion education intervention (n=15). Participants were assessed before and after the intervention with the validated Symptom Concussion Assessment Tool fifth edition (SCAT-5) for quantification of number of symptoms and their severity. Collected data were analyzed using the Mann-Whitney U test and the repeated-measures analysis of variance. Thirty-one participants were enrolled in the study; after 1 control participant was excluded due to incomplete data, 30 patient records were analyzed. The OMM intervention group had a significant decrease in symptom number (P=.002) and symptom severity (P=.001) compared with the concussion education group. When used in the acute setting, OMM significantly decreased concussion symptom number and severity compared with concussion education. This study demonstrates that integration of OMM using a physical examination-guided, individualized approach is safe and effective in the management of new-onset symptoms of uncomplicated concussions. (Clinicaltrials.gov No. NCT02750566).

The Use of Rapid Sequence Magnetic Resonance Imaging of the Brain as a Screening Tool for the Detection of Gross Intracranial Pathology in Children Presenting to the Emergency Department With a Chief Complaint of Persistent or Recurrent Headaches.

The purpose of the study, was to assess the utility of rapid sequence brain magnetic resonance imaging (RS-MRI), as a screening tool to detect gross intracranial pathology in children that present to the emergency department, with a chief complaint of persistent or recurrent headaches. Rapid sequence MRI of the brain is a radiation-free technique that is used to evaluate ventricular size in children with shunted hydrocephalus, who present to the emergency department with symptomatology consistent with shunt malfunction. The study evaluated RS-MRI radiographic findings of 105 children that presented to a busy tertiary care pediatric emergency/trauma center between May 1, 2013, and May 31, 2015. The inclusion criteria for the study are as follows: (1) patient's age up to 12 years, (2) patient history of persistent or recurrent headaches, (3) no history of recent specialized intracranial imaging studies. The exclusion criteria are as follows: (1) a history of recent head injury or trauma, (2) known intracranial pathology, (3) clinical findings consistent with intracranial pathology, (4) patients that required intraprocedural sedation. A detailed explanation was given to the patient's parents/guardian, specifying that this was a "screening test" for detection of gross intracranial abnormalities and not a complete radiological evaluation that would rule out all pathology. Appropriate informed consent was obtained by the attending emergency medicine specialist, and was documented in the patient's medical record. A total of 105 RS-MRI examinations were performed with an average imaging time of 75 seconds. None of the children required intraprocedural sedation, and there were no failed examinations. One patient was excluded from the study due to a pilocytic astrocytoma (not disclosed initially). There were 81 (77%) of 105 normal studies and 24 (23%) of 105 abnormal studies. One patient returned to the emergency department 2 times and was enrolled twice during the 2-year study. Of the 24 abnormal studies, 18 (75%) of 24 cases were diagnosed with sinusitis, and 1 (4.1%) of 24 cases was diagnosed with an abnormal brain mass with mild hydrocephalus due to obstruction of the caudal aspect of the fourth ventricle. Rapid sequence MRI is a radiation-free useful alternative to computer tomography of the brain, when used as a screening tool for children with persistent or recurrent headaches presenting to the emergency department. This rapid imaging modality was particularly useful in identifying children with sinus disease, and contributed significantly to patient/family satisfaction with the care they receive during the emergency department visit. Additionally, RS-MRI screening was successful in detecting a serious neurosurgical emergency in one child with a cerebellar mass causing increased intracranial pressure. Further studies with large sample size are needed to corroborate our findings.

Material properties of the brain in injury-relevant conditions - Experiments and computational modeling.

Material properties of the brain have been extensively studied but remain poorly characterized. The vast variations in constitutive models and material constants are well documented. However, no study exists to translate the variations into disparities in impact-induced brain strains most relevant to brain injury. Here, we reviewed a subset of injury-relevant brain material properties either characterized in experiments or adopted in recent head injury models. To highlight how variations in measured brain material properties manifested in simulated brain strains, we selected six experiments that have provided a complete set of brain material model and constants to implement a common head injury model. Responses resulting from two extreme events representing a high-rate cadaveric head impact and a low-rate in vivo head rotation, respectively, varied substantially. We hypothesized, and further confirmed, that the time-varying shear moduli at the appropriate time scales (e.g., ~5 ms and ~40 ms corresponding to the impulse durations of the major acceleration peaks for the two impacts, respectively), rather than the initial or long-term shear moduli, were the most indicative of impact-induced brain strains. These results underscored the need to implement measured brain material properties into an actual head injury model for evaluation. They may also provide guidelines to better characterize brain material properties in future experiments and head injury models. Finally, our finding provided a practical solution to satisfy head injury model validation requirements at both ends of the impact severity spectrum. This would improve the confidence in model simulation performance across a range of time scales relevant to concussion and sub-concussion in the real-world.

Hypernatraemic hypovolaemia with anaemia: an unusual presentation of primary testicular insufficiency.

Hypogonadal men may experience intense vasomotor symptoms, and vasomotor sweating can occasionally be associated with profound fluid losses. We describe a 37-year-old male, who exhibited persistent hypovolaemic hypernatraemia that was challenging to treat despite a continuous high fluid input (>4–5 L/day). He was noted to have drenching sweats and normochromic anaemia. He had recent traumatic head injury, which resulted in neurocognitive dysfunction, so pituitary function tests were done which showed primary hypogonadism. After exclusion of all other possible causes of excess sweating, hypernatraemia and anaemia, a trial of testosterone therapy was instituted. Sweating dramatically ceased within hours of his first testosterone injection, hydration status normalised within days and anaemia and neurocognitive function progressively improved with continued testosterone replacement. This case demonstrates how, in a susceptible individual, hypovolaemic hypernatraemia can arise from insensible cutaneous fluid loss through eccrine sweating, mediated by vasomotor symptoms of untreated hypogonadism. Although this scenario has not been described in the literature, we felt it needed to be shared with the wider medical community because of how the diagnosis and treatment utterly transformed this patient’s functional status and outcome.Learning points:Hypogonadal men may experience intense vasomotor symptoms and vasomotor sweating can occasionally be associated with profound fluid losses.Whether or not there is also hyperosmolar hypernatraemia, clinicians should always consider the possibility of underlying hypogonadism in men with normocytic anaemia and excessive sweating.Androgen (testosterone) replacement in hypogonadal men can have a dramatic effect on vasomotor sweating and hot flushes.

A key traumatic brain injury initiative in India

A key traumatic brain injury initiative in India

English

Pseudoaneurysm, or false aneurysm, presents rarely as a cause of facial tumor. The condition should be considered by primary care physicians as a cause of facial masses in patients with recent traumatic head injuries. Approximately 337 pseudo aneurysms of the superficial temporal artery (STA) have been reported in the literature since 1644.A good history and careful palpation, auscultation, and ancillary testing easily differentiate pseudo aneurysms from cysts, dermal lesions, and AV fistulas. Timely referral & surgical resection of a pseudoaneurysm is the key in management to avoid complications such as hemorrhage, enlargement and compression of nerves and vessels. We present two cases of traumatic pseudoaneurysm arising from the STA seen in our institution during last 2years period, which suggests that this condition may be more common than reported. We have reviewed the anatomy of the STA and the mechanisms of injury; pathophysiology, pertinent history, and physical findings; differential diagnosis and other diagnostic considerations; INTRODUCTION: Pseudo aneurysms of the superficial temporal artery are a rare and potentially curable cause of facial lumps. Approximately 337 pseudo aneurysms of the superficial temporal artery (STA) have been reported in the literature since 1644. Most pseudo aneurysms are formed as a result of blunt trauma and present as painless, pulsatile tumors that may be associated with neuropathic findings and enlarge in size. Without careful evaluation in the primary care setting, pseudo aneurysms can be easily misdiagnosed and improperly managed. They can, however, be accurately diagnosed through physical examination alone and subsequently treated with surgical ligation. Here we are presenting two cases of traumatic pseudo aneurysms of the superficial temporal artery caused by blunt injury and discuss pertinent diagnosis and treatment options, as well as provide a brief review of the microanatomy and histopathology of pseudo aneurysms. CASE REPORT - I: A 23-year-old farmer, who was referred by a family physician presented with an irregular pulsatile lump in the right temporal region. He had past history of injury by wooden stick at his workplace 2 months ago. He did not have loss of consciousness or laceration at the time of injury. He denied a history of congenital bleeding disorder. The initial swelling he had, after the injury subsided within 4-5 days, but a new, irregular pulsatile mass became palpable 4 to 6 weeks later. Physical examination revealed a 1.5 cm pulsatile irregular shaped lump on the right temporal region. The mass was compressible with digital pressure, but no bruit was appreciable on auscultation. Proximal compression of the temporal artery eliminated the pulsation of the mass.

From the case records of KKCTH: An infant with fever and altered sensorium

Dr. Sumanth AmperayaniThis is a 10-month-old female infant who was previouslywell. She was born to parents of non-consanguineous mar-riage and appropriately immunised. She has fever for 10 daysand is admitted on the 11th day of fever with lethargy andaltered sensorium since morning. She also has 10 episodes ofvomiting since morning. There were no seizures and there isno history of any recent head injury or jaundice or bleedingmanifestations. She was born by normal vaginal delivery atfull term and her birth weight was 3 kg. Till 6 months she wasgaining weight appropriately and was weighing 6 kg at 6months, but after that there has been no weight gain. Onprobing the mother revealed that the maternal grandfather ishaving TB and is on ATT currently. She has grade III PEM ac-cording to IAP classification. Her length is 65 cm and headcircumference(HC)45cm.Heranteriorfontanelisnormalandis not bulging. Weight is less than 5th centile and length isbetween 5th and 10th centiles, and HC is between10th to 25thcentiles. Clinical examination reveals pallor and BCG scar isseen. She is not in shock and her HR is 108/minute and RR is26/minute, regular and no central type of ventilation and herBP is 104/74 mmHg. There are no respiratory signs and mildhepatomegaly (liver span of 7.5 cm) is present. CNS wise herGCS is 10/15 without focal signs. She has generalised hypo-tonia along with brisk reflexes. Her best observed powerseems to be normal. There are no involuntary movements ormeningeal or cerebellar signs. Fundus is appearing normal.What is this infant likely to have sir?Dr. BalasubramanianWe are dealing with an infant with a subacute febrileillness with encephalopathy without meningeal signs or focalneurological signs. The possibilities of Acute CNS Infection arevery high even though there are no meningeal signs

234 Effect of Dialysate Baths on Serum Bicarbonate Levels in Hemodialysis Patients

HYPONATREMIA AFTER HEAD INJURY: A COMPLEX CEREBRORENAL CONNECTION BEYOND SIADH Uma Pakkivenkata, Kambhampati Ganesh, Gurjit Dhatt, Amir Kazory Division of Nephrology, University of Florida, Gainesville, Florida, USA A 76-year-old female who was admitted for subdural hematoma secondary to a fall presented with hyponatremia of 120 mmol/l. The blood pressure was 149/73, pulse 80, and she appeared euvolemic. The brain CT scan revealed a stable subdural hematoma which was managed conservatively. Since the lab data (urine Na 48meq/L, urine osm 401mosm/kg, and serum osm 250mosm/kg) was consistent with the diagnosis of SIADH in the context of recent head injury, the patient was placed on free water restriction. However, this was followed by worsening of hyponatremia to 117 mmol/l and alteration in mental status. A repeat brain CT scan showed worsening hematoma, and she underwent a surgical drainage. Review of the lab results revealed characteristics compatible with increased ADH release associated with features of renal proximal tubulopathy: persistent high urinary levels of electrolytes (e.g. K, Mg, and Phos) despite very low serum levels. Therefore the diagnosis of cerebral salt wasting (CSW) was made and the patient was started on hypertonic saline, which was followed by progressive improvement in serum sodium levels. Two days after resolution of hyponatremia, serum and urine studies were rechecked: serum uric acid remained very low (1.4 mg/dl) and fractional excretion of uric acid did not normalize; a finding that further supported the diagnosis of CSW, rather than SIADH. Other manifestations of proximal tubulopathy (e.g. hypokalemia and hypo-phosphatemia) gradually improved. Hyponatremia after head injury is possibly the manifestation of a complex cerebro-renal connection, with poorly understood underlying mechanisms. In CSW, an unidentified mediator released from the brain disrupts the function of the proximal tubules and leads to leakage of electrolytes into the urine. Interestingly, ADH levels are also increased in CSW; hyponatremia is related to “appropriate” ADH secretion in response to intravascular volume depletion secondary to excessive tubular sodium excretion. As such, CSW and SIADH share several features and represent the biological consequences of a primary insult to the brain that can either be predominant in the brain (SIADH) or in the kidney (CSW). It is of utmost importance to appreciate the subtle differences existing between CSW and SIADH in order to avoid instauration of potentially-harmful management strategies such as this case.

The Structure of Postconcussive Symptoms in 3 US Military Samples

Objective: To evaluate alternative models of symptom clusters for the 22-item Neurobehavioral Symptom Inventory. Participants: Three military samples, including 2 nonclinical samples (n = 2420, n = 4244) and 1 sample of individuals with recent head injury (n = 617). Methods: In the first sample, exploratory factor analysis of Neurobehavioral Symptom Inventory responses was performed with tests of significant factors and model fit. In the other 2 samples, confirmatory factor analysis evaluated the fit of 3 models: 2- and 3-factor models based on the initial exploratory factor analysis, and a 9-factor model based on prior research. Main Outcome Measures: The exploratory factor analysis used 2 tests for the number of factors: Parallel Analysis and Minimum Average Partial test. Confirmatory factor analysis models were evaluated using 2 measures of model fit, Root Mean Square Error of Approximation and Comparative Fit Index. Results: Postconcussive symptoms can be described accurately by the 9 factors. However, the model of 3 intercorrelated factors, reflecting cognitive, affective, and somatic/sensory symptoms, fits the data more parsimoniously with little loss in model fit. Conclusion: Although the 9-cluster result from prior research provides a valid description of the relations among items of the inventory, a 3-factor model, consisting of somatic/sensory, affective, and cognitive factors, provides nearly as good a fit to the data, with greater parsimony. We encourage clinicians and researchers to conceptualize the Neurobehavioral Symptom Inventory in terms of 3 coherent clusters of symptoms rather than as 22 individual items.

When and How to Investigate the Patient with Headache

The common complaint of headache usually has a benign cause, most often a primary headache syndrome. The history and neurologic and general physical examinations usually permit a definitive diagnosis. When in doubt, diagnostic testing is indicated. Certain historical and examination findings increase the likelihood of a secondary headache disorder and the need for diagnostic testing. These include (1) recent head or neck injury; (2) a new, worse, worsening, or abrupt onset headache; (3) headache brought on by Valsalva maneuver or cough; (4) headache brought on by exertion; (5) headache associated with sexual activity; (6) pregnancy; (7) headache in the patient over the age of ~50; (8) neurologic findings and/or symptoms; (9) systemic signs and/or symptoms; (10) secondary risk factors, such as cancer or human immunodeficiency virus (HIV) infection. Less worrisome are headaches that wake the patient from sleep at night, always occur on the same side, or show a prominent effect of change in posture on the patient's pain. Diagnostic studies include neuroimaging, cerebrospinal fluid (CSF) examination, and blood tests, which are selected depending on the patient's history and findings. For most patients, the diagnostic test of choice is a magnetic resonance imaging (MRI) brain scan. Computed tomography (CT) of the brain is usually obtained in the setting of trauma or the abrupt onset of headache. CSF examination is useful in diagnosing subarachnoid bleeding, infection, and high and low CSF pressure syndromes.

Effect of Rosuvastatin on Amnesia and Disorientation after Traumatic Brain Injury (NCT00329758)

Amnesia is a common sequela following traumatic brain injury (TBI), for which there is no current treatment. Pleiotropic effects of statins have demonstrated faster recovery of spatial memory after TBI in animals. We conducted a double-blind randomized clinical trial add-on of patients with TBI (16-50 years of age), with Glasgow Coma Scale (GCS) scores of 9-13, and intracranial lesions as demonstrated by computed tomography (CT) scan. We excluded those patients with recent head injury or severe disability; administration of known drugs as modifiers of statin metabolism; multisystemic trauma; prior use of mannitol, barbiturate, corticosteroids, indomethacin or calcium antagonists; surgical or isolated lesion in brainstem; allergy to statins; previous hepatopathy or myopathy; previous management in another clinic; or pregnancy. Each patient received the same treatment and was randomly allocated to receive either rosuvastatin (RVS) or placebo over a period of 10 days. The primary outcome measures assessed were amnesia and disorientation times using Galveston Orientation Amnesia Test. Additionally, we evaluated plasma levels of interleukin (IL) 1beta, tumor necrosis factor (TNF) alpha, and IL-6, as well as disability at 3 months. We analyzed eight patients with RVS and 13 controls with similar basal characteristics. Using Cox regression analysis, administration of RVS showed a reduction of amnesia time with a hazard ratio of 53.76 (95% confidence interval [CI], 1.58-1824.64). This was adjusted for early intubation, basal leukocytes, basal Marshall and Fisher score, change of IL-1beta levels, and lesion side. IL-6 values at day 3 were increased in the RVS group (p = 0.04). No difference was detected in disability at 3 months. While statins may reduce amnesia time after TBI, possibly by immunomodulation, further trials are needed in order to confirm this positive association.

Nosocomial bacterial meningitis in adults: a prospective series of 50 cases

In order to evaluate characteristics of nosocomial meningitis in adults, we performed a prospective cohort study of 50 episodes of nosocomial bacterial meningitis. These cases were confirmed by culture of cerebrospinal fluid (CSF) in patients aged >16 years. Classic symptoms of bacterial meningitis (headache, neck stiffness and fever) were present in >70% of the episodes, although only a minority (41%) presented with impairment of consciousness. Underlying conditions, such as a history of neurosurgery, recent head injury, CSF leakage or a distant focus of infection, were present in 94% of the episodes. Staphylococcus aureus was the most common pathogen in patients with a history of neurosurgery, causing 10 of 32 episodes (31%). Patients with a distant focus of infection, such as otitis, sinusitis or pneumonia were more likely to have meningitis due to Streptococcus pneumoniae than patients without [six of nine episodes (67%) vs seven of 41 (17%); P=0.01]. Complications occurred in 50% of the episodes and 16% of the patients died. Our study confirms that adults with nosocomial meningitis are a distinct patient group with specific bacterial pathogens, as compared to those with community-acquired bacterial meningitis. Underlying conditions, especially a history of neurosurgery or a distant focus of infection, were present in the large majority of patients, and mortality and morbidity rates were high.

Minor head trauma and isolated unilateral internuclear ophthalmoplegia

Internuclear ophthalmoplegia is a syndrome that develops due to a lesion of the medial longitudinal fasciculus. This lesion is mostly caused by multiple sclerosis (usually bilaterally), and only rarely by head injury. A case is presented of unilateral internuclear ophthalmoplegia as an isolated sequel of minor head trauma, which eventually resolved. A 40-year-old woman with isolated internuclear ophthalmoplegia secondary to closed head trauma with anatomical lesions of the mesencephalon in the region of medial longitudinal fasciculus is described. A minor contusion was detected by magnetic resonance imaging. Diplopia resolved in 5 months. In conclusion, internuclear ophthalmoplegia should be considered in the differential diagnosis in patients with recent head injuries showing adduction impairment. The connection between the clinical picture and anatomical lesions is visualized by magnetic resonance imaging.